Lower Limb Reconstruction & Limb Salvage Surgery in Sydney and the North Shore

Severe injuries or infections in the leg can sometimes put the limb at risk. When bone, tendons or implants are exposed and wounds do not heal, amputation may once have been the only option. Today, leg reconstructive surgery — often referred to as limb salvage — can sometimes help preserve the leg after severe broken bones (fractures) and infections.

These procedures aim to restore healthy tissue cover, protect bone or implants, and reduce the risk of ongoing infection. Surgery is usually performed in stages but not every limb can be reconstructed. Care is highly individualised, and decisions are made by a team of specialists including plastic surgeons.

Dr Varun Harish is a Specialist Plastic and Reconstructive Surgeon (Fellow of the Royal Australasian College of Surgeons - FRACS) with additional advanced international training in limb reconstruction, offering comprehensive limb salvage and reconstruction surgery across Sydney’s North Shore.

Dr Harish assesses complex lower limb reconstruction cases across Sydney, including open tibial fractures, bone infection (osteomyelitis) and exposed implants. He adopts an orthoplastic team approach to provide multidisciplinary, individualised care with a view to limb salvage. Our scope of practice also includes leg reconstruction after infection or trauma, including those complex wounds that have not healed after earlier surgery.

Reconstructive techniques

There are two main ways surgeons use healthy tissue to cover a wound in leg reconstruction — grafts and flaps.

Skin grafts

A skin graft is a thin layer of skin taken from another part of the body and placed over the wound. Because it has no blood supply of its own, it only survives if the underlying wound bed is healthy and has good circulation. Grafts are useful for shallow wounds but cannot be used if bone, tendons, plates or implants are exposed.

Flaps

Flaps are different because they bring their own blood supply, making them more reliable and suitable for deeper wounds or when bone or implants need protection. Flaps may include skin, fat, muscle, bone or combinations of these tissues, depending on the nature of the wound and what structures need to be protected and reconstructed.

Unlike a skin graft, a flap brings its own blood vessels, allowing it to survive even when the wound base or surrounding limb has poor circulation.

Types of flaps include:

• Local or regional flaps – tissue moved from nearby in the same limb, such as the calf muscle rotated to cover wounds around the knee. The blood supply to this tissue is maintained and preserved – it is not detached from the body. These local or locoregional flaps are sometimes referred to as pedicled flaps.

• Free flaps – healthy tissue taken from another part of the body with its blood supply disconnected and then reconnected to blood vessels under a microscope. This is complex microsurgery and is often required for large, deep or infected wounds. These flaps are sometimes referred to as free tissue transfer or a microsurgical free flap.

Why the difference matters (skin graft versus flap)

Skin grafts (including split thickness skin grafts) are thin and rely on the wound bed to survive whereas flaps bring their own blood supply. This means that:

• Grafts are simpler operations with faster recovery but limited applications.
• Flaps are more complex and sometimes performed in stages but provide strong, durable tissue that is essential when bone, tendons or implants need protection.

In limb reconstruction surgery, several types of flaps can be used to restore healthy coverage, protect exposed bone or implants, and improve blood flow to the leg. The examples below outline some of the most common reconstructive options used in lower limb reconstruction across Sydney’s North Shore and beyond.

Techniques used in lower limb reconstruction

The choice of technique depends on the wound’s size, depth, and location, as well as the nearby blood supply.

Common reconstructive options include:

• Reverse sural flap – skin and tissue from the back of the calf are rotated down towards the heel or ankle while staying attached to their own blood vessels. It’s often used for ankle and heel wounds (see image above).
• Gastrocnemius flap – part of the calf muscle is turned forward to cover defects around the knee or upper shin. This provides a durable, blood flow-rich tissue layer for protecting exposed bone or implants.
• Gracilis flap – a slender inner-thigh muscle can be harvested and transplanted (free flap) to fill smaller leg or foot wounds, offering minimal to no impact on function.
• Anterolateral thigh (ALT) free flap – skin and soft tissue from the outer thigh are taken with their blood vessels, then reconnected to new vessels in the lower leg under a microscope. This option is used for larger or more complex wounds where local tissue is insufficient.

Choosing the right technique

The decision about which method to use depends on:

• The underlying problem (for example, an incision not healing after a joint replacement)
• The location of the wound (shin, knee, ankle, hip or foot)
• The wound’s depth and size
• The blood supply to the wound and the limb overall
• Patient factors such as diabetes, smoking and circulation

As a plastic and reconstructive surgeon on Sydney’s North Shore, Dr Harish performs complex microsurgery (free flaps) for lower limb reconstruction.

Recovery and rehabilitation

Timelines vary, but complex reconstructions may involve staged surgery, hospital monitoring of flaps, and periods of physiotherapy before weight-bearing. Recovery is therefore highly variable. 

Many patients need multiple operations performed in stages. This may include removal of infected bone or implants, soft tissue reconstruction (flap surgery), insertion of new implants, and flap revision.

Some reconstructions (flap surgeries) involve long hospital stays with close flap monitoring, while others allow earlier mobility.

Physiotherapy is almost always needed, sometimes for many months. Walking aids may be required during recovery, and some patients have lasting limitations even after reconstruction.

It is important to understand that these are complex problems requiring individualised treatment. Surgery does not always succeed, and in some cases amputation may be the safest or most functional outcome. Success rates and recovery vary and are discussed individually.

Frequently Asked Questions

For Referrers

Referrals are commonly received from:

• General Practitioners (GPs) – for wounds that are not healing or where bone, tendon or implants are exposed
• Orthopaedic surgeons – for open fractures or implant / joint-replacement / broken-bone wound complications
• Vascular surgeons
• Infectious-disease specialists – for bone infection not controlled with antibiotics